Provider Demographics
NPI:1639188238
Name:CLODFELTER, JR., REYNOLDS
Entity Type:Individual
Prefix:
First Name:REYNOLDS
Middle Name:
Last Name:CLODFELTER, JR.
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 JOHN HUMPHRIES WYND
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5438
Mailing Address - Country:US
Mailing Address - Phone:919-783-5431
Mailing Address - Fax:
Practice Address - Street 1:3141 JOHN HUMPHRIES WYND
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5438
Practice Address - Country:US
Practice Address - Phone:919-783-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000762Medicaid